Basic Information
| Provider Information | |||||||||
| NPI: | 1154390854 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GREENWOOD LEFLORE HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | GORTON CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1410 | ||||||||
| Address2: | ATTN CLINIC ADMINISTRATION | ||||||||
| City: | GREENWOOD | ||||||||
| State: | MS | ||||||||
| PostalCode: | 389351410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6624597189 | ||||||||
| FaxNumber: | 6624591147 | ||||||||
| Practice Location | |||||||||
| Address1: | 1401 RIVER RD | ||||||||
| Address2: | ATTN CLINIC ADMINISTRATION | ||||||||
| City: | GREENWOOD | ||||||||
| State: | MS | ||||||||
| PostalCode: | 389304030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6624597189 | ||||||||
| FaxNumber: | 6624591147 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2006 | ||||||||
| LastUpdateDate: | 08/25/2008 | ||||||||
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| AuthorizedOfficialLastName: | ADAMS | ||||||||
| AuthorizedOfficialFirstName: | JERRY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6624597000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 09014025 | 05 | MS | MEDICAID |